This certificate only needs to be completed if
the foreign national is 12 years of age or older.
1 Certificate
> Please tick the applicable situation
2 Signing
2.1 Name
2.2 Place and date
2.3 Signature
Appendix
Antecedents Certificate
n I certify that:
• I have never been sentenced to imprisonment or a custodial measure for committing a crime;
• I have never been sentenced to perform community service for committing a crime;
• I have never been imposed an unconditional fine for committing a crime;
• I have never accepted an out-of-court settlement for committing a crime;
• I have never been imposed a penalty order by a public prosecutor for committing a crime;
• I am currently not subject to prosecution for committing a crime;
• I have never been responsible for one of the following categories of acts as referred to in Article 1F of
the 1951 Refugee Convention: a crime against peace, a war crime, a crime against humanity, a serious
non-political crime (for example murder or terrorism), or acts contrary to the purposes and principles of
the United Nations (for example terrorist acts); and
• I am aware of the fact that a sentence for committing a crime may result in a refusal or termination of the
right of residence.
• I have not submitted any incorrect data during earlier residence procedures;
• I did not reside in the Netherlands illegally in the past;
• I am not subject to any entry ban.
n I am unable to certify the above for the following reasons:
I have completed this form truthfully.
|
Place Day Month Year
|
|
Please note!
If this antecedents certificate has not been completed truthfully, this will have consequences for
your right of residence.
b01